NOTE ON A CASE OF OSTEO-ENCHONDROMA OF THE CEREBELLUM.

841 Whether the absorption of this gas would have the effect of there will be slight, if any, falling in of the sides of the rendering the anaesthesia even more perfect remains to be former, and, in all probability, some noise of in-rushing air will be audible. Having adjusted the face-piece satisseen by experiment. I now propose to describe the apparatus before alluded to, factorily, gas is turned on at the stopcock (T), and a certain (seewoodcut). The face-piece (F) is furnished with two valves, number of expirations are allowed to escape through the valve (Ev). As far as my experience goes, it is best to an inspiratory valve (iv), and an expiratory valve (EV). The inspiratory valve (IV) is mounted upon the sliding allow nearly one-half of the contents of the bag to be plate (sP), which can be moved up and down by the rod (R) inhaled, and then exhaled into the surrounding atmosphere; which is attached to it. When the plate (sp) is raised, as and to effect this, four or five respirations are usually in the woodcut, the valve (iv) is in contact with the orifice requisite. The rod (R) is then depressed. The patient now of the tube coming from the two-way stopcock (T), and gas breathes directly in and out of the bag, and the usual rushes past it during inspiration, but not during expiration; evidences of anaesthesia ensue. The total number of when, however, the plate is pushed down by the rod (R), respirations necessary will, of course, vary with each indithe valve (IV) is also displaced, and gas can pass backwards vidual patient; the average number in one hundred cases and forwards through the orifice previously guarded by the was forty-five. I usually wait for some slight twitching of valve (IV). The expiratory valve (EV) is situated upon the the muscles before removing the face-piece. The period of upper part of the face-piece. When the rod (R) is raised, as anaesthesia which ensues is, I think, not quite so long as in the woodcut, the valve (EV) is capable of acting during that which is met with under ordinary circumstances, expiration; when, however, the rod (R) is depressed, the although Mr. Read, one of the dental surgeons at the circular damper (D) is pushed down upon the valve (EV), National Dental Hospital, assures me that he sees no and the latter is rendered inactive. It will therefore be seen that when the rod (R) is raised, both valves are capable of acting; when, however, the rod (R) is depressed, all valve action is suddenly abolished, and gas can only pass in and out of the orifice of the tube previously guarded by the valve (IV), the rod (R) which necessarily comes over this orifice offering practically no obstruction to the passage of the gas. The two-way stopcock (T)

difference in this respect between the anaesthesia which is obtained by using plenty of nitrous oxide and that induced by administering two gallons in the manner 1 have described. I have been unable to ascribe any unusual aftereffects to this mode of administering the gas. Further experience is necessary before more detailed comparisons can be made between the anaesthesia thus induced and that obtained by employing several gallons of gas. The experience I have had in the above method of administering nitrous oxide gas has led me to the conclusion that it can be employed in all short operations, especially in hospitals where economy has to be considered. I believe that the average amount of nitrous oxide used for each patient at the National Dental Hospital is five or six when the ordinary apparatus is employed. At hospitals where small fees are charged for the privilege of having the gas administered, it might be possible to reduce or abolish these fees, except under special circumstances. Economy in nitrous oxide is doubtless to be secured in others ways than that which I have mentioned. Many anaesthetists use the "Supplemental Bag," which can be adapted to ordinary face-pieces, and by its use less gas is certainly necessary than under ordinary circumstances. How much less will, of course, depend upon various conditions. I believe, however, that, as a rule, it is necessary to use a great deal more than two gallons of gas. If two gallons of gas will suffice for short operations, it may be found practicable for the anæsthetist who is called to administer gas to one patient either to dispense with the heavy gas-bottle or to substitute for it a much smaller and

gallons

portable one. Hawksley of 357, Oxford-street, is face-piece; and I have to thank him more

the maker of the for the care and attention with which he has carried out my instructions. Somerset-street, Portman-square, W. Mr.

is fixed other to

the one side to the face-piece (F), and on the piece of tubing connected to a Cattlin bag holding two gallons of gas. The latter (as is commonly the case) is NOTE ON A filled from the gas-bottle through a stout piece of indiarubber tubing; and I have found it convenient to have a CASE OF OSTEO-ENCHONDROMA OF THE small stopcock with a bayonet joint interposed between the CEREBELLUM.1 bag and the gas-bottle, so that the two may be quickly and BY CHARLES ATKIN, F.R.C.S ENG., readily disconnected, if necessary. The anaesthetist can, HOUSE SURGEON, INFIRMARY, SHEFFIELD. under these circumstances, attach the bag by any simple contrivance to his coat button, and with the two gallons of MR. SHAW, of Attercliffe, Sheffield, in making the postgas and the face-piece he is equipped for most short operations. mortem examination on the body of a boy aged eleven, The following are the details of the method: the bag and in the right lobe of the the tubing between it and the face-piece having been filled found a hard bony substance was meningitis following death of The cause with gas (by placing the two-way stopcock as in the figure), cerebellum. weeks’ otorrhoea of three is accuthe face-piece (which is also arranged as shown), history. In the right lobe of only that the faceIt be seen fitted to the face. will in the substance of the organ embedded the patient’s rately cerebellum, piece is so made that it can be grasped firmly at its back part underneath the grey matter, was a hard body about the size by the hand of the anaesthetist, whose forefinger and thumb of a bean, half an inch by three-eighths of an inch, weighing will then be able to press its sides over the nose of the patient. seventeen It was not enclosed in a cyst or surInspiration now takes place through the air-hole (n) of the rounded bygrains. undue vascularity or softening, and had any two-way stopcock, and expiration takes place through the apparently nothing to do with the cause of death. It was valve (Ev). I am in the habit of testing the fittmg of no smaller one being in the neighbourhood, quite firm the face-piece by placing my finger for a moment over single, and hard, giving at once the idea that it consisted of bony the air-hole (H), and then asking the patient to "try to breathe." If no air enters at any part, the sides of the face- tissue. The mother stated that he has always been a boy, especially up to the age of four, suffering from piece will be observed to fall in as the tendency towards a delicate "water on the head,’ that he was late in teething, had vacuum is set up; whereas if air should gain admission it sometimes 1 (as does) between the face-piece and the face, Read before the Sheffield Medico-Chirurgical Society, April 23rd, 1885. on

a

842 had scarlet fever or measles, and had always been lively, attentive, and quick at learning. The parents were apparently healthy, though the father had a strumous and three brothers aged respectively phthisical appearance, nineteen, fourteen, and nine all had otorrhoea. The interest of the case lies chiefly in the origin and nature of the growth. After decalcification the bony tumour was carefully cut in two, one half being cut up into sections for the microscope and the other preserved in spirit. On viewing the cut surface the growth was seen to consist of two portions: one, a central nucleus with prolongations, and the other surrounding tissue of evidently different structure. Under the microscope four different tissues are seen-first, the stellate nucleus, consisting of fine granular matter readily taking aniline colours, staining yellow with picrocarmine ; secondly, well-marked hyaline cartilage, forming a complete capsule for the nucleus, which sends its prolongations in and amongst it in a very irregular manner: some true bone, and most externally parallel bundles thirdly, of fibro-cellular tissue, which were, previous to decalcification, as hard as bone. There is no doubt that the tumour is perfectly innocent; it is not a chondrifying or calcifying sarcoma; it is not a mass of brain sand. In the granular centre, brain elements, such as Deiter’s cells or Purkinje’s corpuscles, are absent. One might imagine that it might be degenerated additamentary corpus dentatum, but even then the stellate cells are wanting. Is the nucleus of the tumour hypertrophied neuroglia due to circumscribed encephalitis ? I have searched for records of similar growths, but have found nothing at all comparable to it. Calcifications of tumours of the brain are uncommon, but still well known. Bevan Lewis has recorded a calcified angioma, and Ross quotes one by Meschede. As well as with regard to its never

of the

cavity into the superior meatus of the nose, and a drainage-tube passed through it and out at the right nostril, and left with one end projecting through the incision and the other through the nostril. The drainage-tube remained in position till November 10th (nearly four months), when it

removed. Dec. 8th.-Opening where drainage-tube projected quite closed; replaced by small depressed cicatrix. An irregular bony edge can still be felt, but the fluctuating swelling has

was

entirely disappeared.

LIVERPOOL ROYAL INFIRMARY. OF NECK TREATED BY TRACHEOTOMY AND THE INSERTION OF DEEP SUTURES ; REMARKS,

SUICIDAL WOUND

(Under the care of Mr. REGINALD HARRISON.) FOR the following notes we are indebted to lir. H. Pearson. H. 0-,aged fifty-six, no occupation, a weakly and ill-nourished looking man, was brought to the Royal Infirmary early on the morning of July 29th, 1884, with a severe wound in the neck, as follows: There was a deep cut on a level with the upper border of the thyroid cartilage, and extending, on the surface, about two inches to either side of the middle line; this wound, inflicted by a razor, passed horizontally backwards, so as to divide all the structures attached to the upper border of the thyroid cartilage, and, still deeper, dividing the pharynx nearly half way through. On making efforts at swallowing, the thyroid cartilage moved upwards and forwards through the wound in a most curious way. It was stated that he had lost a quantity seat and the fact of its causing no symptoms, it is curious of blood, but there was no bleeding of consequence on his in another way-viz., that it is an exception to the rule arrival at the hospital. The following treatment at once suggested itself : to perform tracheotomy, and then to bring that heterologous enchondromata are generally malignant. the divided parts together with strong deep wire sutures. To the attainment of this object the patient was anassthetised, and the trachea opened above the isthmus; a large tube was inserted so that respiration might be as free as possible; next, the base of the epiglottis, which on being released from the thyroid cartilage had become tilted upwards OF and backwards, was drawn down and fixed to the centre of the HOSPITAL upper border of the thyroid cartilage by means of a mediumsized wire suture; then, by means of a curved mounted BRITISH AND FOREIGN. needle, a strong wire was passed on either side through the upper part of the lateral wing of the thyroid cartilage Nulla autem est alia pro certo noscendi via, nisi quamplurimas at morborum et dissectionurn historias, tum aliorurn tum proprias collectas and carried around the hyoid bone ; on tightening these two habere, et inter se comparare.—MORGAGNi De Sed. et Caus. Morb., sutures the deep soft parts were brought neatly together, lib. iv. Prooemium. and the hyoid bone maintained in its proper relation to the thyroid cartilage; finally, the surface wound was neatly GUY’S HOSPITAL. closed over the deep sutures by means of fine silver wire. DISTENSION OF FRONTAL SINUS TREATED BY INCISION The man was kept in bed surrounded by a tent, the temAND DRAINAGE; CURE. perature of the room maintained at 65°, and the air (Under the care of Mr. HIGGENS.) constantly moistened by a steam kettle; two ounces of DISTENSION of the frontal sinuses from the accumulation sanitas to each large kettleful of water served very weh to keep the atmosphere pleasant and sweet. He was of fluid is somewhat rare, especially when the fluid is nonordered to have milk and beef-tea thrice daily through an purulent. Incision, with the application of the trephine, œsophageal tube, also beef-tea night and morning by the when the bone has not been absorbed from pressure or rectum. He was troubled a little with slight bronchial removed by disease, followed by free drainage, is the best irritation for a days afterwards, but his temperature rose above 103.2°. never The greater part of the wound In addition to the external treatment. ordinary opening, Mr. Higgens made one from the distended sinus into the united rapidly, leaving only a fine fistulous tract leading from the pharynx to the right angle of the cicatrix. As nasal cavity, thus providing further drainage and allowing this opening showed no tendency to heal, a plastic procedure the external wound to close at an earlier date. was resorted to on Aug. 29th -viz., the tract was thoroughly Eliza H—, aged eleven, admitted July 20th, 1884. The scraped with a Volckmann’s spoon, and the walls of the history wag that usually given in these cases-a blow across fistula brought together by means of a strong deep suture; the nose from a fall six or seven years previously. Some this was then covered in by bringing together the edges of . eighteen months later the child had scarlet fever, and at the previously dissected up skin. This wound united that time a small abscess formed at the inner canthus of the kindly, and on Sept. 12th the tracheotomy tube was removed, right eye; this burst and gave no further trouble. Two and on the 18th (a week before his discharge), this last years ago the right eye began to water, and a swelling wound having closed, the patient was permitted to take appeared at the side of the nose; this has gradually increased. soft solid food by the mouth. On admission there was a fluctuating swelling surrounded Remarks by Mr. HARRISON.—This wound was so large by irregular bony edges, situated at the inner angle of the that it was quite out of the question to leave it to heal right orbit rather above the position of the lacrymal sac. without maintaining the divided structures in good position, The swelling is rather larger when the patient is in the and moreover, to this end, it appeared a necessity to have erect position than when lying down; it is also rather free respiration below the site of injury. Similar treatment smaller in the morning than later in the day. seems to suggest itself as commendable and safe for wounds July 21st.-An incision made into the swelling gave exit of much less extent than the above, if not, indeed, to all to a large quantity of thick, opaque, yellowish discharge; cases of cut-throat whenever the pharynx or larynx has the finger passed through the incision entered a consider- been laid in communication with the surface of the neck. able cavity. An opening was made through the lower part The four deep sutures used had, up to the time of the

A Mirror

PRACTICE,

few